Sh 430 Form PDF Details

Navigating the requirements and processes for obtaining an Asbestos Handling License in New York State is a crucial step for companies involved in asbestos work. The SH 430 form, issued by the Division of Safety and Health License and Certification at the Harriman State Office Campus, presents a comprehensive application process for both original licenses and renewals. Applicants must provide detailed information about their company, including their name as registered with the New York State Department of State, their Federal Employment Identification Number, and the type of organization, among other specifics. The form also delves into the nature of the asbestos work to be performed, emphasizing the need for a designated supervisor with a valid Department of Labor Asbestos Certificate Number for abatement projects. Further, it requires disclosures about the applicant's legal and regulatory compliance history, highlighting any past violations or convictions. Compliance with disability insurance and workers' compensation insurance is mandated as well, alongside certification concerning child support obligations. The form emphasizes the necessity of honesty and accuracy in providing all requested information, warning that false statements are subject to legal penalties. This meticulous documentation process underscores New York State's commitment to ensuring the safety and health standards in asbestos management, aiming to protect both workers and the general public from asbestos-related hazards.

QuestionAnswer
Form NameSh 430 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesny application asbestos, sh430 form, asbestos handling license, nysdol asbestos license application

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Bates #

Lic #

Approved

Reason (If disapproved):

Check #

File #

Disapproved

 

 

 

 

 

 

 

 

 

Division of Safety and Health

License and Certification

Harriman State Office Campus

Building 12, Room 161A

Albany, NY 12240

Application for an Asbestos Handling License

1. Type of license:

Original ($500 fee)

License Number (Renewal only):

Renewal ($300 fee)

2. Name of company or organization (Company name must be exactly as registered with NYS Department of State.):

 

3a. Federal Employment Identification Number:

4.

 

Type of organization:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Partnership

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3b.

New York State Unemployment Insurance Employer

 

 

 

 

Sole Proprietorship

 

 

 

 

 

 

 

Registration Number (E.R. No.):

 

 

 

 

Government

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Incorporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

When did the company begin operations under its current name?

 

a.

Mo/Day/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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7a.

Street address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7b.

Mailing address, if different:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Duly authorized representative:

 

 

 

 

a. Name of representative:

d. Business telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Social Security Number:

e. Fax number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Job title - (circle one): Administrator, Assistant, Director,

f. Email address:

 

 

 

 

 

 

Manager, Officer, Supervisor, Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Business Mailing address of the duly authorized representative:

 

 

 

 

If “Government” is checked in item 4, Skip items 9 through 11.

SH 430 (05/18)

9.List all owners, partners and shareholders who own five percent or more of the company and all officers and directors of the company (attach additional sheets if necessary).

Name

Home address (Street, City, State, Zip)

Soc. Sec. No.

Percent ownership

Role- (select one)

Director, Officer, Owner Partner, Shareholder, Other

10. Is the company an affiliate of any other organization? Yes

No

If yes, list name(s) and address(es) of the

organizations (attach additional sheets if necessary).

 

 

Company name

FEIN

Address

(Street, City, State, Zip)

11.List all owners, partners and shareholders who own ten percent or more of any affiliates and all officers and directors of such affiliates (attach additional sheets if necessary).

Name

Home address (Street, City, State, Zip)

Soc. Sec. No.

Percent

ownership

Role - (select one) Director, Officer, Owner Partner, Shareholder, Other

12.Check at least one of the types of asbestos work to be performed:

Note: If you check abatement, answer Question 13. If you don’t, you must complete Question 14. Abatement

Management Planning

Project Design

Monitoring

Inspection

Air Monitoring

Other (please explain)

13.Designated Supervisor:

Name of Supervisor (if abatement is checked in question 12)

Signature of Supervisor (No co-signs or stamps):

Department of Labor Asbestos Certificate Number:

14.Affirmation statement: If abatement is not checked in question 12, place an X in the box to affirm the following statement.

The firm’s activities shall not include actual

asbestos abatement operations during the period for which the license is valid.

Affirmed

Social Security Number:

15.Firm History

You must answer either “Yes” or “No” to every question listed below. Provide details on a separate sheet.

Have you the applicant, your authorized representative, the firm, any affiliate, any predecessor company or entity, owner of 5% or more of the firm’s shares, director, officer, partner or proprietor been subject to any of the following (New applicants must provide previous 5 years and renewal applicants must provide for time since last application.):

YesNo

A conviction of a crime?

A Notice of Violation and/or Order to Comply, an administrative hearing or proceeding, or a determination involving a violation of the New York State Labor Law or any rule or regulation issued under the Labor Law?

A citation, an administrative hearing or proceeding, or a determination involving a violation of Local

 

 

Laws 70 and 76, and the asbestos control program rules and regulations enforced by the City of

 

 

New York?

Any violation of the Asbestos Training regulations (10NYCRR73) of the New York State Department of Health?

A violation of any federal, state or local

a.apprenticeship requirement?

b.health regulation or statute?

c.environmental regulation or statute?

d.education regulation or statute?

e.law or regulation governing pensions including Employee Retirement Income Security Act (ERISA)?

f. law or regulation governing payment of prevailing wages including the Davis-Bacon Act?

g. law or regulation governing wages and hours including the Fair Labor Standards Act

 

 

(FLSA)?

A citation, administrative hearing or proceeding for violation of a federal Occupational Safety and

 

 

Health Administrative (OSHA) standard?

A federal or state suspension or debarment?

A prevailing wage or supplement payment violation?

A nonrenewal, suspension or revocation of any business or professional license?

A failure to submit any quarterly payroll reports (Form NYS-45) or failure to pay any liabilities due to

 

 

the New York State Unemployment Insurance Division.

 

 

16. Disability Insurance

Disability Insurance is required in NYS if the applicant is a “covered employer,” i.e., if one or more of the applicant’s employees is employed in NYS for a least 30 days in any calendar year; the 30 days need not be consecutive. Covered employees must submit a copy of the Certificate of Disability Insurance (form DB-120.1) or Certificate of Disability Self Insurance (form # DB-155). Non-covered employers must submit a Certificate of Attestation of Exemption (CE-200) issued by the Worker Compensation Board.

Check one of the following:

I have disability insurance coverage. (Submit form DB-120.1 or DB-155.)

I am exempt from disability insurance coverage. (Submit form CE-200.)

This license is for a NYS government entity, or governmental subdivision within NYS, or a public school.

Acceptable forms of proof of

Workers’ Compensation Insurance

A)C-105.2: Certificate of Workers’ Compensation Insurance

B)CE-200: Certificate of Attestation of Exemption

C)U-26.3: State Insurance Fund’s version of C-105.2

D)SI-12: Certificate of Workers’ Compensation Self- Insurance

E)GSI-12: Certificate of Group Workers’ Compensation Self-Insurance

F)GSI-105.2: Certificate of Participation in Workers Compensation Group Self-Insurance

Check one of the following:

17.Worker’s Compensation Insurance

You must provide proof that you have Workers’ Compensation Insurance coverage or an exemption from such coverage (see list of acceptable forms in box at left). The New York State Department of Labor, License and Certification Unit, Building 12, Room 161A, State Campus, Albany, NY 12240 must be listed as a certificate holder. This certification may be obtained from the Workers’ Compensation Board District Office nearest you.

If you need more information about insurance contact the Workers’ Compensation Board, 180 Livingston Street, Brooklyn, NY 12248; (800) 877-1373, or www.wcb.state.ny.us.

___

I have worker compensation coverage and the compensation coverage is of the classification for the type of asbestos work

 

to be conducted. (Submit form C-105.2, U-26.3, SI-12, GSI-12, or GSI-105.2.)

I currently have no worker compensation coverage because:

___

I have no employees and do not intend to hire employees. (Submit form CE-200.)

___

I have no employees at this time. (Submit CE-200.) When I do hire employees, I will obtain worker compensation coverage

 

classified for the asbestos work conducted and submit an update with the proof of coverage.

___

This license is for a NYS government entity.

18.Certification of Child Support Obligations (not required for corporations or government entities)

Are you under an obligation to pay child support? If yes, complete items #1 - #4

Yes

No



 

 

 

 

 

 

 

 

 

1.

I am making payments in accordance with a plan agreed upon by the parties.

Yes

No



 

2.

I am four months or more behind in the payment of child support.

Yes

No



3.

My child support obligation is the subject of a pending court proceeding

Yes

No



 

 

 

 

 

 

 

4.

I am receiving public assistance or supplemental security income.

Yes

No



 

Note: Any additional partner(s) in a partnership must complete form GO 1 Certificate of Child Support Obligations. To obtain the form go to www.labor.ny.gov, type GO 1 in the search box then click on GO 1 Appendix to a License.

19. Applicant Statement

This statement must be signed by the contractor, or a representative of the contractor who is authorized to sign on behalf of the company or organization named in this application.

Iunderstand that:

(a)This application is subject to verification and I agree to provide any additional documentation as required.

(b)Outside sources may be contacted to verify information contained in this application; and I give permission for the disclosure of any information which may be needed to process this license application.

(c)Failure to provide any of the requested or required information may result in rejection of this application.

(d)In order to complete this form, I must provide certain personal information. The authority to collect this information is found in the New York State Labor Law. This information will be maintained and used to process the application I am filing with the License and Certification Unit. Failure to provide this information may result in the inability to process my application. I also understand that by signing this I am granting permission to the Commissioner of Labor to provide access to my Unemployment Insurance (U.I.) benefit file.

(e)I swear or affirm as true the following:

(1)all persons employed by the applicant on any asbestos project whose duties involve the removal, encapsulation, enclosure, repair or disturbance of asbestos, or any handling of asbestos material that may result in the release of asbestos fiber or the supervision thereof, shall have valid asbestos handling certificates;

(2)the applicant will abide by all the rules and regulations promulgated pursuant to this article; and

(3)all the statements and information I have provided in this application are true to the best of my knowledge and belief.

False statements made herein are punishable as a class A misdemeanor pursuant to Section 210.45 of the penal law.

Signature of the Contractor or Duly Authorized Representative (No cosigns or stamps):

____________________________________________________________________________

Title: __________________________________________________________Date:__________

Prepare this application and submit:

a.An original to the New York State Department of Labor, License and Certification Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240. Retain a copy for your records.

b.A non-refundable fee of $500 for an original or $300 for a renewal license in the form of a check or money order, made payable to the Commissioner of Labor.

c.A photocopy of the Supervisor certificate issued to the contractor or to the supervisor designated as the contractor’s agent, listed in Box 13.

d.The required insurance certification.

How to Edit Sh 430 Form Online for Free

The asbestos handling license renewal filling out procedure is easy. Our PDF tool enables you to work with any PDF document.

Step 1: Click on the "Get Form Here" button.

Step 2: Now you can enhance your asbestos handling license renewal. You need to use the multifunctional toolbar to insert, remove, and adjust the content material of the document.

Fill out all of the following segments to complete the document:

portion of blanks in application asbestos license

Note the essential particulars in b New York State Unemployment, Registration Number ER No, Corporation Partnership Sole, Incorporation a MoDayYear, b State, When did the company begin, a Street address, City, State, Zip Code, b Mailing address if different, Duly authorized representative a, d Business telephone number, b Social Security Number, and e Fax number segment.

application asbestos license b New York State Unemployment, Registration Number ER No, Corporation Partnership Sole, Incorporation a MoDayYear, b State, When did the company begin, a Street address, City, State, Zip Code, b Mailing address if different, Duly authorized representative a, d Business telephone number, b Social Security Number, and e Fax number fields to fill out

Jot down the significant data in g Business Mailing address of the, and If Government is checked in item box.

Filling in application asbestos license part 3

The Name, Home address Street City State Zip, Soc Sec No, Percent ownership, Role select one Director Officer, Is the company an affiliate of, If yes list names and addresses of, organizations attach additional, Company name, FEIN, Address Street City State Zip, List all owners partners and, affiliates attach additional, Name, and Home address Street City State Zip section is the place where either side can place their rights and obligations.

application asbestos license Name, Home address Street City State Zip, Soc Sec No, Percent ownership, Role select one Director Officer, Is the company an affiliate of, If yes list names and addresses of, organizations attach additional, Company name, FEIN, Address Street City State Zip, List all owners partners and, affiliates attach additional, Name, and Home address Street City State Zip blanks to fill out

Finalize the file by checking all of these fields: Check at least one of the types, Note If you check abatement answer, Abatement Management Planning, Designated Supervisor, Name of Supervisor if abatement is, Affirmation statement If abatement, Signature of Supervisor No cosigns, The firms activities shall not, Department of Labor Asbestos, Affirmed, and Social Security Number.

Completing application asbestos license step 5

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